When surveyors from the Joint Commission on Accreditation of Healthcare Organizations show up unannounced next year, hospital managers will have to demonstrate that their facility can control infections, manage medications and maintain adequate staffing for the volume and clinical condition of patients. In addition, they'll have to show the hospital is attaining relevant patient-safety goals set by the JCAHO. Previous unannounced visits have been designed around a hospital's past compliance problems or patient complaints, as well as a handful of "fixed performance areas" evaluated in all unannounced visits. Performance areas for 2004 are different because they emphasize the process of providing care rather than rote compliance with standards, JCAHO spokeswoman Charlene Hill said. For example, an evaluation of staffing performance previously would have involved asking for proof of compliance with certain human resource standards. In 2004 the evaluation could encompass other accreditation areas that affect staffing, such as how hospital leadership fosters good staffing practices and how staffing figures into a hospital's environment of care. Random unannounced surveys, which affect about 5% of all hospital organizations each year, will end in January 2006 when the JCAHO begins conducting all regular accreditation surveys on an unannounced basis. -- by John Morrissey
JCAHO to try new tack in unannounced surveys
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